Money for health - moving to the root of the problem

There has been some debate recently about personal financial incentives to achieve healthy behaviour. The Harvard philosopher Michael Sandel has been brilliantly exploring the issue from many angles [ listen to radio 4 debate here: http://www.bbc.co.uk/podcasts/series/r4sandel ]

The argument against payment incentives is characterised as bribing people to be healthy and wasting money. Needless to say The Sun, The TaxPayers’ Alliance, and The Tories are not the biggest fans [ http://bit.ly/JLmcZB ]

However, the debate to-date largely misses a crucial link. Health and wellbeing are determined largely by behaviours / lifestyles (e.g. smoking, alcohol, diet, physical activity); and also directly by socioeconomic factors (e.g. income, education, occupation, housing, family, networks, culture). These behaviours / lifestyles are also determined by the same socioeconomic factors - "the causes of the causes” if you like. The pattern almost always follows that lower socioeconomic circumstances increases adverse behaviours and so impacts on health. There is plenty of evidence to support these pathways and also that shows that because of the adverse social and economic circumstances the "choice" of the adverse behaviour is not one necessarily freely taken (e.g. healthy foods are not so affordable or available; smoking and drinking often arise out of the chronic stress of poverty and unemployment).

We cannot, therefore, try to really improve lifestyles and behaviours without improving the underlying social and economic circumstances. To change this may be considered as "up stream" or requiring major political change and beyond the remit of health (or other) services. And obviously progressive taxation and / or better distribution of wages are the major solutions. However, incentivising with monetary / payment is an attempt in a relatively small, local, and direct way to address these socioeconomic causes of the causes.

A Dundee programme – called quit4u – offering payment of £12.50 a week (in supermarket food vouchers) to encourage people living in deprived circumstances to quit smoking has been shown to work. The two year evaluation, just published, demonstrates improved quit rates at 3 months and even 12 months [ full evaluation here www.healthscotland.com/documents/5827.aspx ]. At its launch the Dundee initiative was met with much the same aversion, which has dominated the debate on this area. But, at its heart has been an ethos of understanding this socioeconomic link and trying to do something, albeit in a small way, about it. So praise must go to NHS Tayside for taking this bold and groundbreaking action in the face of much hostility. We urge other health boards and Scottish Government to follow suit and take more positive action with the powers they have to make a difference to the lives of those most in need if we are going to tackle inequalities in health and wellbeing.

Hospital Acquired Infections

The closure of eight wards at Royal Alexandra Hospital in Paisley because of an increase in people showing symptoms of the Norovirus bug has thrown the spotlight back on HAI's. Two people suffering from diarrhoea and vomiting died in the hospital. NHS Highland also reported an increase in the number of cases of diarrhoea and vomiting with Raigmore Hospital in Inverness closing two wards to new admissions and a ward at Caithness General is also shut.

Scotland's Chief Medical Officer, Sir Harry Burns has stressed that Norovirus cases were decreasing in number, saying: "The number of cases of norovirus, the number of outbreaks, has fallen over the past few years. So things are stable and probably going in the right direction. It's something we are seeing less of, a 16% reduction in the figures over the past two or three years."

Sir Harry also highlighted the importance of hygiene in tackling the virus: "Hand-washing is probably one of the most important things we can do. It is dealt with by soap and water; conventional clean hands. Hand hygiene among NHS staff in Scotland at an all-time high".

More generally on HAIs, the Health Protection Scotland Point Prevalence Survey, which involved 13,558 patients, 844 wards and 75 hospitals, records a snap shot of all types of infections on the day of the survey. The April 2012 report highlights that prevalence of healthcare associated infections was 4.9 per cent in acute hospitals and 2.5 per cent in non-acute hospitals – a significant reduction on 2006 levels.

Health Secretary, Nocola Sturgeon commented,  "the overall level of infections has reduced by one third since 2006 and cases of some types of infection which cause particular concern, such as C.diff and MRSA blood stream infections, have fallen by over 75 per cent. This is good news but I am in no doubt that there is still more that can be done as we strive to embed quality in all aspects of patient care in Scotland. This is a substantial report and so I have asked the HAI Task Force National Advisory Group to consider the report’s findings and to provide advice on its implications for future HAI policy and priorities.”

So good progress, however, HAI's are a long way from being eradicated. On average at least one patient in every 20 on a ward in acute care at any one time has an HAI.  Scottish Labour's Shadow Health Secretary, Jackie Baillie, said: "The fact six people have died in recent days, 20 wards have been closed and more than 100 people across Scotland are suffering from norovirus symptoms should be a stark reminder the battle against hospital superbugs is far from over."

Hand washing disciplines and infection control staff will probably help mitigate the worst aspect of the problem, but it will not alter the underlying reasons for the development of HAIs. This is beacuse they are an unintended consequence of the factory style hospital care we have developed in recent years. Occupancy and bed turnover rates are at an unheard of level. This together with waiting time targets put constant pressure on hospitals to move ever increasing numbers of sick people through the hospital, together with a similar increase in different vistors.

We also have non-NHS reasons for the increase including farmers using antibiotics. Again, something that is unlikely to change quickly. The overall proportion of bloodstream and urinary infections has risen, with E.coli a growing problem in both. Health Protection Scotland has reported that the prevalence of E.coli was higher (20.8% versus 6.7%) than that reported in the previous Scottish PPS (survey). It confirmed the growing resistance to antibiotics although even this could not account for the rising prevalence of E.coli in Scottish hospitals.

So while an army of protocols, staff and lotions are mitigating the problem of HAIs, we should remember that the underlying cause is in our factory approach to modern acute care. That isn't going to change quickly, if at all.

Healthier Scotland - April 2012

The April edition of the SHA Scotland E-Bulletin - Healthier Scotland is now out!

The Alcohol (Public Health & Criminal Justice) (Scotland) Bill

New consultation from Scottish Labour MSP's Richard Simpson and Graham Pearson on their proposed Alcohol (Public Health & Criminal Justice) (Scotland) Bill.

While SHA Scotland supports minimum alcohol pricing we also recognise that this is only one measure of many that needs to be taken to tackle alcohol abuse in Scotland. 

 The Bill contains a total of 14 measures, spanning public health and criminal justice policy including:

• Stop retailers flaunting the new ban on bulk-buy promotions by closing down a loophole in the law
• Require government to report on progress on public health and child protection licensing objectives
• Clamp down on alcohol marketing in public places, especially where children may be exposed
• Introduce a legal limit of 150 mg per litre of caffeine of pre-mixed alcoholic drinks
• Evaluate and improve alcohol education and public information campaigns
• Tighten the law to prevent unfair discrimination against 18-21 year olds in off-sales
• Give local communities a greater say in licensing decisions
• Establish a National Licensing Forum to drive forward improvements in licensing laws and devise solutions to emerging problems
• Give local authorities powers to roll out ‘bottle-tagging’ to help the authorities crack-down on retailers selling to those under age and proxy purchasing
• More targeted disposals for those convicted of alcohol-related offences
• Fast track treatment for individuals taken into custody who are perceived to have an alcohol problem
• Give courts powers to ban individuals from drinking in specified places to help curb alcohol-related criminal or disorderly behaviour and to protect others from such behaviour
• Extend the successful Drug Treatment and Testing Orders (DTTO) to cover offences where alcohol has been a factor
• Require GPs to be notified of any new conviction by patients where alcohol was a factor to ensure patient receives appropriate treatment and support

This is a comprehensive paper that sets out a cogent case for the measures described. The consultation paper can be downloaded here. The SHA Scotland will be considering this at our May meeting and we would encourage members to read the paper and let us have your views.

Why We Support the Alcohol Minimum Pricing Bill

The Socialist Health Association Scotland supports the Alcohol Minimum Pricing (Scotland) Bill being debated at Holyrood today.

The price of alcohol misuse paid by Scottish society is well over 2 billion pounds, with the cost to the NHS estimated at over 400 million.

But, the true price of alcohol is borne by our communities and families.

Alcohol has an important place in our cultural and social lives and in our economy. But our relationship with alcohol has gone in wrong direction down the wrong road. In fact we have driven off the road and into a lamp post – drunk and disgraced.

The harmful effects of alcohol misuse are also widely known in terms of its impact on health and wellbeing and on health inequalities – where alcohol contributes much to the shameful inequality in life expectancy that blights the people of Scotland.  

Sadly, alcohol misuse hits the poorest hardest. But, as Ed Miliband said “the gap between rich and poor doesn’t just harm the poor. It harms us all”. And So problem drinking is not confined to certain groups, it affects us all. Recent data from the Scottish Health Survey show that we are all drinking too much.

Our efforts to tackle Scotland’s increasing alcohol culture have thus far been pretty hopeless. You may not be surprised that health education and awareness campaigns are the main alternative proposal from the drinks lobby. Such campaigns don’t work – are usually expensive and largely ineffective.

Many of the arguments against alcohol minimum pricing echo those we heard when the Labour-Liberal administration were legislating to ban smoking in public places. Landmark public health legislation which we can be proud in Scotland to have led the way on and which thre rest of the UK followed. Legislation, which in a short time has delivered dramatic reductions in heart disease and deaths with none of the adverse effects muted at the time.

The thrust of this Bill is to increase the cost of alcohol. Simple. Alcohol is too cheap – fact! It is over half as affordable now than it was in the ‘80s. And it’s not surprising then that consumption has doubled in the same period.

There is now a large body of evidence from around the world that links the price of alcohol to the level of consumption and in turn to the level of alcohol-related harm.

And, yes we recognise that taxation could achieve the same benefits, with the added advantage that revenue would go to the state rather than the retailers. However, excise duty is a reserved power and there is no way George Osborne and David Cameron will act. A compensatory levy, similar to the recent 'Tesco Tax', could cover this point. But it needn’t be an absolute condition for support.

The only other major argument against this legislation is that it will disproportionately affect low income groups.  Alcohol, at present, already disproportionately effects low income groups. The way supermarkets target and sell alcohol as a loss leader, row upon row of cheap cider and booze is a disgrace and no different to and arguably more harmful than a drug dealer up a close.

A robust evaluation of the policy, as it is introduced, should be undertaken which explores any adverse impacts – particularly, in relation to ensuring the most vulnerable communities are not harmed and inequalities widened. And the promised sunset clause to fully mitigate.

There is wide support for this, and the NHS, the police, the media, children’s charities, wide sections of civil society including religious groups, and public opinion. Up against who? The alcohol lobby and some licensing boards.

Like the smoking ban, this legislation is not perfect, nor is it going to be a panacea to all our alcohol problems. And of course it needs to be part of a wide range of initiatives, which need to be brought forward. But, there is no doubt it is part of the solution. 

Abstaining in parliament on such an important issue does not feel right and will not look right.

The right thing to do is to support the Bill.

Scottish Labour Fringe Meeting

SHA Scotland was on the fringe at last weekend's Scottish Labour Party conference in Dundee. 'Health policy - where next?' was sponsored by UNISON Scotland.

UNISON's Gordon McKay chaired the well attended meeting and opened by referring to the Progress journal's implied support for the English health reforms and marketisation of the NHS. Some 'comrades' clearly have lost the plot! He contrasted this with SHA Scotland's new policy journal Healthier Scotland.

Dr David Conway kicked off the debate with SHA Scotland's principles and his analysis of where we needed to take the debate.  He welcomed the level of political consensus in Scotland around health inequalities but recognised that we have huge health challenges to address and that requires new thinking on how to address them.

Shadow Health Secretary Jackie Baillie MSP debunked the myth that NHS Scotland was somehow protected from cuts - £319m was being cut. But her main message was that the agenda for Scottish Labour is wider than simply healthcare. We need to relentlessly focus on life chances for the youngest children. 

There were many excellent contributions from the floor. In particular a lot of debate around social care integration in Scotland.  Including concerns that the Change Fund is being used to privatise not integrate care services. The Highland pilot in particular is heading for disaster according to more than one contribution.

Good debate as ever from a knowledgeable audience. 

Healthier Scotland - The Journal

The first edition of our new policy journal - Healthier Scotland has been published.

The March 2012 edition was launched at our fringe meeting at the Scottish Labour Party Conference in Dundee.

This edition includes:

 

Future health policy	Jackie Baillie MSP
Minimum price for alcohol?	Dave Watson
Low pay is bad for your health	Eddie Follan
Health impact of climate change	Dr David Conway
NHS Scotland ‘leading edge’ of industrial relations	John Gallacher
Housing and health	Murdo Mathison
Local healthcare in Norway	Eberhard ‘Paddy’ Bort
Scotland in the midst of an obesity epidemic	Richard Simpson MSP
English health reforms	Stephen Adshead
NHS Scotland – the real challenges	Matt McLaughlin
Coronary heart disease	Janet McKay